Among these sources of outcome data, it is well recognized that data derived from large prospective randomized clinical trials most accurately reflect the outcomes that can be anticipated when a procedure is performed in clinical practice. Unfortunately, as of the time this document was prepared, there have been no large randomized multicenter clinical trials performed to determine the safety and efficacy of catheter ablation of AF.
A Work in Progress …
“A Mitral Valve, Flapping in the Breeze, Prolapsed into the Atrium …”
Johns Hopkins Medicine has a long tradition of prioritizing patients, and striving for the bottom rung are the anonymous poor.
If, for example, you catch a bullet on a Baltimore street corner, or your mother presents you at the ER as a feverish welfare child, then it’s open season for the med students, well meaning as they may be. They can practice on you because if their actions result in an adverse outcome—which is to say that if you are mangled or killed—nobody will question said outcome, precisely because… you are a nobody.
At the other end of the spectrum are wealthy and prominent patients, who get treated by doctors who have already learned what not to do from the mistakes inflicted upon the lower classes.
My wife landed somewhere in the middle. We got snookered by all the hype from US News into thinking that she was going to be treated by the best doctor at “The Best Hospital in America.”
Hugh Calkins, MD was to maneuver tiny wires around in my wife’s heart and burn scar tissue in the wall of the atrium to stop atrial fibrillation.
The job required someone with a cool head and a keen eye, and Hugh Grosvenor Calkins, MD, FACC, FAHA, FHRS, Professor of Medicine, Director of the Electrophysiology Lab at Johns Hopkins University School of Medicine—and graduate of Harvard Medical School—assured us that he had done plenty of these procedures, and, he said, “experience counts.” So we knew we were in the best of hands. What we didn’t know is that Professor Calkins—according to what he later told colleagues—follows the practice at most teaching hospitals wherein “the attending shows up to be there during the burn.”
What he meant by that was this:
The patient is etherised upon a table, and wheeled into the laboratory. A student of the treatment performs and is responsible for routine aspects of the procedure. According to the rules, all this is to be done under close supervision. With blue vinyl fingertips feeling their way under bright white light, the trainee practices finding the femoral vein in the patient’s groin, high up inside the thigh, pressing and probing and picking a spot and then pushing the point of a large needle into the flesh until it punctures and there is blood.
The trainee then inserts the sheath for the catheter into the vein and snakes it up into the pumping heart. Then he inserts the catheter wire up into the sheath, and here is where one would expect the experienced attending physician to step in because it is a very tricky business to navigate a thin wire around in a beating heart guided by cloudy X-Ray imagery, even if you know what you’re doing.
But since he only “shows up to be there during the burn,” Hugh Calkins was presumably relaxing with colleagues down in the doctor’s lounge or out selling TASER guns and reloading presses for shootingauthority.com while a young cardiology trainee by the name of Richard Wu—whom we’d never met—was sweating out a decision in the lab. He had a stranger laid out on the table before him and a new type of catheter in his hand.
It appears that young Wu wasn’t sure into which chamber of the heart the catheter was to be inserted.
He went for the left ventricle (it says right on the box to not do that) and the catheter got tangled in the muscles of her mitral valve. Her chart read: “only the first 50% of the circular portion of the catheter tip could be withdrawn into the sheath and pulsatile motion could be appreciated.”
They were trying to cajole the catheter back into its sheath, but it was tugging right back, like they’d hooked a five pound bass. A nurse noted here that the “patient is waking and moving around, with chest pain @ 7/10.”